Reference chart for knee flexion following total knee arthroplasty: a novel tool for monitoring postoperative recovery

Kinematic Alignment Technique Outperforms Mechanical Alignment in Simultaneous Bilateral Total Knee Arthroplasty: A Randomized Controlled Trial

BACKGROUND

The aim of this study was to compare the clinical results of kinematic alignment (KA) with those of mechanical alignment (MA) in single-stage bilateral total knee arthroplasty.

METHODS

In this double-blinded randomized controlled trial, 65 patients who had bilateral knee osteoarthritis underwent simultaneous bilateral total knee arthroplasty. One knee was randomly selected to be operated on with the calipered-KA technique and the other with MA. The participants were assessed via the Oxford Knee Score, Western Ontario and McMaster Universities Osteoarthritis Index questionnaire, and visual analog scale before the surgery and the same plus the Forgotten Joint Score at their last follow-up visit, 2 years postoperatively. Maximum knee flexion and the time reaching maximum knee flexion, named the recovery time, were also recorded. Hip-knee-ankle angle, medial proximal tibial angle, and lateral distal femoral angle were measured before and after the surgery using 3-joint-view radiographs.

RESULTS

At 2 years, there were significant differences between the KA and MA techniques in terms of duration of surgery, recovery time, and final Western Ontario and McMaster Universities Osteoarthritis Index, Forgotten Joint Score, and maximum flexion range in favor of KA (P < .05), but no significant difference in visual analog scale score or Oxford Knee Score. In patients who have a preferred knee, the KA knee was preferred over the MA knee by most patients. No prosthetic failure or revision was reported in either group.

CONCLUSIONS

The KA technique yields acceptable functional outcomes compared to the MA technique. The KA technique was associated with a shorter surgery time, a faster recovery time, and higher patient satisfaction in 2-year follow-ups. Larger multicenter studies with longer follow-ups are warranted to confirm these findings.

LEVEL OF EVIDENCE

I.

Development and content validation of a questionnaire identifying patients' functional priorities and abilities after hip or knee arthroplasty

PURPOSE

To develop a self-report questionnaire evaluating functional priorities after hip or knee arthroplasty and evaluate patients' understanding of its items and conceptual relevance.

METHODS

A self-report questionnaire was first developed based on the International Classification of Functioning, Disability, and Health (ICF) core set for osteoarthritis (OA). In the second stage, two research physiotherapists thoroughly reviewed and refined the questionnaire, and another physiotherapist conducted cognitive think-aloud interviews with 18 patients to assess the face and content validity of the questionnaire.

RESULTS

All categories and corresponding activities of ICF core set for OA were used to develop the questionnaire. Several questionnaire issues were identified and addressed. Most challenges were related to comprehension, followed by item ordering and visual elements. Patients identified ambiguous wording which we subsequently simplified. Ten activities of the core set were excluded due to lack of face validity, two activities were added, and four activities were modified.

CONCLUSION

The findings suggest that the ICF core set for OA needs to be adjusted for patients undergoing hip or knee arthroplasty and highlight the feasibility of applying a modified core set to assess functional priorities after hip or knee arthroplasty.

Characterization of the Relative Change in Objective and Subjective Metrics by Baselining Patients Who Have Wearable Technology Before Total Knee Arthroplasty

BACKGROUND

Wearable sensors and associated supporting technologies (ie, patient applications) can provide both objective (joint position, step counts, etc.) and subjective data (ie, pain scores and patient-reported outcome measures) to track a patient's episode of care. Establishing a subjective and objective baseline of a patient's experience may arguably be beneficial for multiple reasons, including setting recovery expectations for the patient and demonstrating the effectiveness or success of the intervention.

METHODS

In this pilot study, we characterized a subset of patients (n = 82 from 7 surgeons) using a wearable sensor system at least 6 days before total knee arthroplasty and provided postsurgical data up to 50 days postintervention. The 5-day average before surgery for total step counts (activity), achieved flexion and extension on a progress test (functional limit) and visual analog scale daily pain score were calculated. The difference from baseline was then calculated for each patient for each day postsurgery and reported as averages.

RESULTS

On average, a patient will experience a relative deficit of 4,000 steps immediately following surgery that will return to near-baseline levels 50 days postintervention. A 30° deficit in flexion and a 10° deficit in extension will return at a similar rate as steps. Relative pain scores will worsen with an increase of approximately 3 points immediately following surgery. However, pain will decrease by 2 points relative to baseline between 40 and 50 days.

CONCLUSIONS

The results of this pilot study demonstrate a method to baseline a patient's presurgical subjective and objective data and to provide a reference for postsurgical recovery expectations. Applications for these data include benchmarking for evaluating intervention success as well as setting patient expectations.

Early- to Mid-Term Review of a Prospective, Multi-Center, International, Outcomes Study of an Anatomically Designed Implant with Posterior-Stabilized Bearing in Total Knee Arthroplasty

Background and Objectives: National joint registries report higher total knee arthroplasty (TKA) revision rates in posterior-stabilized (PS) systems compared to non-posterior-stabilized designs. The purpose of this study was to investigate the implant survivorship and clinical outcomes of an anatomic implant with a PS bearing. Materials and Methods: An early- to mid-term follow-up of a prospective, multi-center, non-controlled outcomes study of patients who received primary TKA between November 2014 and June 2017 was performed. A total of 800 cases using PS bearings that were implanted in 664 patients were monitored post-operatively for their implant survivorship and adverse events for up to five years. The Knee Society Knee and Function scores, patient satisfaction, the five-dimensional European Quality of Life questionnaire, and range of motion (ROM) were evaluated pre-operatively and post-operatively at six weeks, six months, one year, two years, three years, and five years. Results: The mean follow-up period was 3.7 ± 1.3 years, and the three-year implant survival rate was 99.3% (95% CI: 98.4%, 99.7%) with five revisions during the five-year follow-up. Patient satisfaction was 96.1% at six weeks and increased to 99.3% at one year. All patient-reported outcome measures significantly (p < 0.0001) increased up to the one-year follow-up and then remained stable up to the five-year follow-up. Conclusions: This study supports the excellent survivorship and patient-reported outcomes of the Persona® Knee system using cemented, fixed bearing, posterior-stabilized components with minimal complications at early- to mid-term follow-up in an international Asian population. Ongoing observations are being performed to investigate the mid- to long-term survivorship and clinical outcomes associated with this knee system.

Nationwide implementation of personalized outcomes forecasts to support physical therapists in treating patients with intermittent claudication: Protocol for an interrupted time series study

INTRODUCTION

Shared decision-making is the cornerstone of patient-centered care. However, evidence suggests that the application of shared decision-making in physical therapy practice is limited. To elicit shared decision-making and thereby potentially improve patient outcomes for patients with intermittent claudication, we developed a decision support system. This decision support system provides personalized outcomes forecasts that visualize the estimated walking distance of an individual patient. We hypothesize that personalized outcomes forecasts can support physical therapists in personalizing care to the needs and priorities of the individual patient to improve therapy outcomes.

RESEARCH OBJECTIVES

The primary aim is to evaluate the impact of personalized outcomes forecasts for patients with intermittent claudication to optimize personalized treatment. Second, this study aims to evaluate the process of implementation.

METHODS

This study uses a prospective interrupted time series (ITS) design. Participating physical therapists are divided into four clusters. Every month of the study period, a new cluster will be invited to begin using the decision support system. We aim to include data of 11,250 newly referred patients for physical therapy treatment. All therapists associated with a network of specialized therapists (Chronic CareNet) and patients treated by these therapists are eligible to participate. The decision support system, called the KomPas, makes use of personalized outcomes forecasts, which visualize the estimated outcome of supervised exercise therapy for an individual patient with intermittent claudication. Personalized outcomes forecasts are developed using a neighbors-based approach that selects patients similar to the index patient (a.k.a. neighbors) from a large database. Outcomes to evaluate impact of implementation are patients' functional and maximal walking distance, quality of life and shared decision-making. Process evaluation will be measured in terms of utilization efficacy, including the outcomes dropout rate and reasons to (not) use the personalized outcomes forecasts. Data will be routinely collected through two online systems: the Chronic CareNet Quality system, and the website logs of the decision support system. Additionally, observations and semi-structured interviews will be conducted with a small subset of therapists.

ETHICS

Formal medical ethical approval by the Medical Research Ethics Committees United 'MEC-U' was not required for this study under Dutch law (reference number 2020-6250).

Digital Rehabilitation after Knee Arthroplasty: A Multi-Center Prospective Longitudinal Cohort Study

Rehabilitation for total knee replacement (TKA) often involves in-person therapy sessions, which can be time consuming and costly. Digital rehabilitation has the potential to address these limitations, but most of these systems offer standardized protocols without considering the patient's pain, participation, and speed of recovery. Furthermore, most digital systems lack human support in case of need. The aim of this study was to investigate the engagement, safety, and clinical effectiveness of a personalized and adaptative app-based human-supported digital monitoring and rehabilitation program. In this prospective multi-center longitudinal cohort study, 127 patients were included. Undesired events were managed through a smart alert system. Doctors were triggered when there was a suspicion of problems. The drop-out rate, complications and readmissions, PROMS, and satisfaction were collected through the app. There was only 2% readmission. Doctor actions through the platform potentially avoided 57 consultations (85% of alerts). The adherence to the program was 77%, and 89% of the patients would recommend the use of the program. Personalized human-backed-up digital solutions can help to improve the rehabilitation journey of patients after TKA, lower healthcare-related costs by lowering the complication and readmission rate, and improve patient reported outcomes.

Development of reference charts for monitoring quadriceps strength with handheld dynamometry after total knee arthroplasty

Purpose: To develop reference charts that describe normative quadriceps strength recovery after total knee arthroplasty (TKA) as measured by handheld dynamometry (HHD).Materials and Methods: We conducted a retrospective analysis of post-TKA quadriceps strength recovery in a longitudinal dataset consisting of both clinical and research HHD data. We created sex-specific models for recovery using Generalized Additive Models for Location, Scale, and Shape. We created reference charts from the models to display the recovery of population centiles over the first six postoperative months.Results: A total of 588 patient records with 1176 observations were analyzed. Reference charts for both sexes demonstrated a rapid increase in quadriceps strength over the first 60 postoperative days followed by a more gradual increase over the next 120 days. Males appeared to demonstrate faster recovery and greater strength on average compared to females. The quadriceps strength recovery of three female patient records was plotted on the reference chart to illustrate the charts' potential clinical utility.Conclusions: These reference charts provide normative data for quadriceps strength recovery after TKA as assessed by HHD. The reference charts may augment clinicians' ability to monitor and intervene upon quadriceps weakness-a pronounced and debilitating post-TKA impairment-throughout rehabilitation.Implications for RehabilitationHandheld dynamometry (HHD) is an objective and clinically feasible method for assessing muscle strength, but normative HHD values are lacking for quadriceps strength recovery after total knee arthroplasty (TKA).We created sex-specific reference charts which provide normative quadriceps strength HHD values for the first 180 days after TKA.These reference charts may improve clinicians' ability to monitor and intervene upon post-TKA quadriceps strength deficits.

Impact of Personalized Outcomes Forecasts on Clinical Reasoning of Physical Therapists in Intermittent Claudication: A Vignette Study

OBJECTIVE

Guidelines recommend supervised exercise therapy and lifestyle counseling by a physical therapist as initial treatment for patients with intermittent claudication. However, guidelines provide only a crude estimate of the outcomes that therapists and patients might expect from treatment. The purpose of this study was to explore the impact of personalized outcomes forecasts (POFs) on the decision-making process of physical therapists and to learn lessons on facilitating the use of forecasts in daily practice.

METHODS

A vignette-based, think-aloud interview study design was used. The participants were physical therapists trained in treating patients with intermittent claudication. Vignettes described fictitious patients diagnosed with intermittent claudication and included POFs. A directed approach was used to code, organize, and describe the data. Transcripts were analyzed using a thematic approach.

RESULTS

Sixteen therapists participated in the study. Three themes were identified: (1) setting and contextualizing treatment expectations, (2) setting (shared) goals and (de)motivating the patient, and (3) establishing and monitoring the treatment plan. Therapists mentioned that POFs could be useful for setting expectations and realistic treatment goals, contextualizing expected treatment response, stimulating patients to achieve their goals, and deciding on treatment frequency and treatment timing. Therapists thought POFs would be of less use for changing treatment goals during follow-up visits or for establishing intensity or type of training.

CONCLUSION

To overcome challenges that may arise when adopting POFs in daily practice, adequate training of physical therapists should be conducted. Potential areas to address with training include statistical and data literacy as well as guidance on integrating POFs with existing treatment protocols.

IMPACT

The use of POFs by physical therapists might contribute to a more person-centered care approach. The insights provided by this study on the first use of POFs by physical therapists can serve as an example and lesson on how to optimally implement such supporting tools into daily practice.

Using a Learning Health System to Improve Physical Therapy Care for Patients With Intermittent Claudication: Lessons Learned From the ClaudicatioNet Quality System

Routinely collected outcomes data can be used to improve physical therapy care through benchmarking, personalization, continued education, and treatment optimization. This article describes how a nationwide infrastructure to routinely collect data from daily practice was created and how these data were used through a support system (called the ClaudicatioNet Quality system) to improve physical therapy care for patients with intermittent claudication in the Netherlands. ClaudicatioNet is a nationwide network of 2100 specialized physical therapists, providing high-quality supervised exercise therapy in combination with lifestyle counseling. The ClaudicatioNet Quality system uses a large national registry in which specific relevant health outcomes have been routinely collected since 2015. These data have then been used in turn to assess quality of care and provide transparency to therapists and other stakeholders. The Quality system is intended to serve as a learning health system, to support continuous learning at the therapist, practice, and network level. In this approach, individual patients and physical therapists are provided with opportunities to personalize, benchmark, and evaluate (and possibly alter) a treatment plan using routinely collected data from historical patients. The Quality system is described based on the essential elements of a learning health system. The challenges and lessons learned in developing the Quality system also are described.

IMPACT

The use of routinely collected health outcomes can, if implemented correctly, facilitate continuous learning among physical therapists and contribute to person-centered care. This example of a learning health system might serve as a blueprint for physical therapists on how to optimally implement and distill meaning from routinely collected clinical data.